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Mediate.org Intake Form

Intake of disputes

Name(Required)

First Last

Phone(Required)

Email(Required)

Enter Email Confirm Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Do you have an attorney or representative?(Required)

Yes

Attorney or Representative Name:(Required)

Attorney/Representative Email(Required)

Enter Email Confirm Email

Office Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Do you have contact information for the Responding/Other party?(Required)

Yes

Responding/Other Party Full Name:(Required)

Responding/Other Party Email(Required)

Enter Email Confirm Email

Responding/Other Party Phone(Required)

Responding/Other Party Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Type of Dispute(Required)

How long has this been going on?(Required)

Please tell us in one paragraph what the dispute is about.

Have You Agreed to a Mediator with the Responding/Other Party?(Required)

Yes

What are you looking for in a mediator?

Able to meet in-person

Able to meet online

Able to meet privately and jointly with the parties

Trauma-informed

Mediator Full Name

First Last

Mediator Email(Required)

Enter Email Confirm Email

Mediator Phone(Required)

Acknowledgement of Mediation Program Rules(Required)

I acknowledge and agree to the Mediation Program Participation Agreement (below)

Mediation Program Participation Agreement

Voluntary Participation: Participation in the mediation process is entirely voluntary. Any party may withdraw from the mediation at any time by providing notice to the mediator and the other party(ies).

Confidentiality: All discussions, negotiations, and documents exchanged during mediation are confidential. Participants agree not to disclose any information from the mediation to outside parties, except as required by law or as agreed upon by all parties involved.

Good Faith Effort: Participants are expected to engage in the mediation process in good faith, meaning they will participate honestly, openly, and with a genuine intent to resolve the dispute.

Respectful Communication: All participants must communicate respectfully and courteously, without interrupting or using hostile or disrespectful language. Personal attacks and aggressive behavior will not be tolerated.

Commitment to Resolution: Participants should come to mediation prepared to explore all reasonable options for resolving the dispute and be willing to compromise to reach a mutually agreeable solution.

Neutral Mediator: The mediator is a neutral facilitator whose role is to help parties communicate and explore options for resolution. The mediator will not take sides, provide legal advice, or make decisions for the parties.

Full Disclosure: Participants agree to provide full and accurate information relevant to the dispute, ensuring that all necessary facts are presented for effective mediation.

No Legal Representation: Participants acknowledge that the mediator is not acting as a legal representative. Parties are encouraged to seek independent legal advice before and after the mediation if needed.

No Recording: Audio or video recording of the mediation sessions is strictly prohibited unless all parties and the mediator consent in writing.

Agreement in Writing: Any agreement reached during mediation must be put in writing and signed by all parties to be enforceable. Verbal agreements are not binding.

Compliance with Mediation Outcomes: If a settlement is reached, participants agree to abide by the terms of the settlement. If a settlement is not reached, participants may pursue other dispute resolution options, including litigation.

Termination of Mediation: The mediator has the discretion to terminate the mediation if it is determined that continuing the process is no longer productive or if any party violates the agreed-upon rules.

Costs and Fees: Participants agree to the cost-sharing arrangements for the mediator's fees and any administrative expenses associated with the mediation process.

Acceptance of Terms and Conditions of Service(Required)

I Accept the Terms and Conditions of Service

By participating in the Mediation Program, all parties involved acknowledge that they have read, understood, and agree to be bound by the following Terms and Conditions of Service:

Scope of Services: The Mediation Program offers a neutral facilitator to assist parties in reaching a mutually agreeable resolution to their dispute. The mediator will not impose a solution or provide legal advice. All parties acknowledge that the mediation process is intended to facilitate communication and negotiation, not to adjudicate or make binding decisions.

Confidentiality: All communications, negotiations, and documents exchanged during the mediation process are confidential. No party shall disclose any information obtained during mediation to any third party without the express written consent of all parties involved, except as required by law.

Voluntary Participation: Participation in the mediation process is voluntary. Any party may choose to withdraw from the mediation at any time by providing written notice to the mediator and the other parties. Withdrawal from mediation does not affect any legal rights or remedies the parties may have outside of mediation.

Good Faith Effort: All parties agree to participate in the mediation process in good faith. This includes being honest, open, and cooperative, and having a genuine willingness to resolve the dispute. Failure to participate in good faith may result in termination of the mediation process.

Mediator’s Role and Authority: The mediator acts as a neutral facilitator to assist parties in reaching a resolution. The mediator does not have the authority to make any decisions, impose any solutions, or provide legal advice. All parties acknowledge that the mediator is not acting as a legal representative and is not responsible for the outcome of the mediation.

No Legal Advice or Representation: The Mediation Program and its mediators do not provide legal advice or representation to any party. Parties are encouraged to seek independent legal advice before, during, and after the mediation process to understand their rights and obligations.

Binding Nature of Agreements: Any agreement reached during mediation must be documented in writing and signed by all parties to be enforceable. Verbal agreements are not binding. Once signed, the written agreement is considered a binding contract, enforceable under applicable law.

Termination of Mediation: The mediator reserves the right to terminate the mediation at any time if it is determined that further mediation efforts are unlikely to result in a resolution, if any party violates these terms and conditions, or if the mediator believes that the mediation is being used for an improper purpose.

Fees and Costs: All parties agree to share the fees and costs associated with the mediation process as agreed upon in advance. The Mediation Program reserves the right to require payment in advance or to establish a payment schedule.

Limitation of Liability: The Mediation Program and its mediators shall not be liable for any damages, losses, or claims arising from the mediation process. The parties agree to release and hold harmless the Mediation Program and its mediators from any and all claims arising from the mediation, except in cases of willful misconduct or gross negligence.

Governing Law: These terms and conditions shall be governed by and construed in accordance with the laws of the state in which the mediation is conducted. Any disputes arising under these terms and conditions shall be resolved exclusively in the courts located in that state.

Amendments: These terms and conditions may be amended or modified only by a written agreement signed by all parties and the mediator.

Mediate.org

Mediate.org Intake Form

Mediation Program Participation Agreement

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